Introduction Currently, The nature and scope of Clinical Ethics Protocols in Madrid are not well understood.Objectives The main objective is to describe the features of ‘guideline/recommendation’ type CEPs that have been or are being developed by existing Clinical Ethics Committees in Madrid. Secondary objectives include characterisation of those CECs that have been the most prolific in reference to CEP creation and implementation and identification of any trends in future CEP development.Methods We collected CEPs produced and in process by CECs accredited (...) in the public hospitals in Madrid, Spain, from 1996 to 2008.Results CECs developed 30 CEPs, with 10 more in process. The most common topic is refusal of treatment . If CEPs addressing terminal illness, Do-Not-Resuscitate orders and advance directives are placed into a separate ‘ethical problems at the end of life’ category, this CEP subject emerges as the most common . There is a relationship between the age of the CEC and the development of CEPs . CECs now seem to be more likely to engage in CEP development.Conclusions The CECs in Madrid, Spain, have developed a significant number of CEPs and there is a trend towards continued development. The most frequent topics are ethical problems at the end of life and refusal of treatment by the patient. (shrink)

Background and objectives: Physicians are exposed to matters of existential character at work, but little is known about the personal impact of such issues. Methods: To explore how physicians experience and cope with existential aspects of their clinical work and how such experiences affect their professional identities, a qualitative study using individual semistructured interviews has analysed accounts of their experiences related to coping with such challenges. Analysis was by systematic text condensation. The purposeful sample comprised 10 physicians (including three women), (...) aged 33–66 years, residents or specialists in cardiology or cardiothoracic surgery, working in a university hospital with 24-hour emergency service and one general practitioner. Results: Participants described a process by which they were able to develop a capacity for coping with the existential challenges at work. After episodes perceived as shocking or horrible earlier in their career, they at present said that they could deal with death and mostly keep it at a distance. Vulnerability was closely linked to professional responsibility and identity, perceived as a burden to be handled. These demands were balanced by an experience of meaning related to their job, connected to making a difference in their patients’ lives. Belonging to a community of their fellows was a presupposition for coping with the loneliness and powerlessness related to their vulnerable professional position. Conclusions: Physicians’ vulnerability facing life and death has been underestimated. Belonging to caring communities may assist growth and coping on exposure to existential aspects of clinical work and developing a professional identity. (shrink)

Background and objectives: Physicians are exposed to matters of existential character at work, but little is known about the personal impact of such issues.Methods: To explore how physicians experience and cope with existential aspects of their clinical work and how such experiences affect their professional identities, a qualitative study using individual semistructured interviews has analysed accounts of their experiences related to coping with such challenges. Analysis was by systematic text condensation. The purposeful sample comprised 10 physicians , aged 33–66 years, (...) residents or specialists in cardiology or cardiothoracic surgery, working in a university hospital with 24-hour emergency service and one general practitioner.Results: Participants described a process by which they were able to develop a capacity for coping with the existential challenges at work. After episodes perceived as shocking or horrible earlier in their career, they at present said that they could deal with death and mostly keep it at a distance. Vulnerability was closely linked to professional responsibility and identity, perceived as a burden to be handled. These demands were balanced by an experience of meaning related to their job, connected to making a difference in their patients’ lives. Belonging to a community of their fellows was a presupposition for coping with the loneliness and powerlessness related to their vulnerable professional position.Conclusions: Physicians’ vulnerability facing life and death has been underestimated. Belonging to caring communities may assist growth and coping on exposure to existential aspects of clinical work and developing a professional identity. (shrink)

Background The consistency of codes governing disclosure of terminal illness to patients and families in Islamic countries has not been studied until now. Objectives To review available codes on disclosure of terminal illness in Islamic countries. Data source and extraction Data were extracted through searches on Google and PubMed. Codes related to disclosure of terminal illness to patients or families were abstracted, and then classified independently by the three authors. Data synthesis Codes for 14 Islamic countries were located. Five codes (...) were silent regarding informing the patient, seven allowed concealment, one mandated disclosure and one prohibited disclosure. Five codes were silent regarding informing the family, four allowed disclosure and five mandated/recommended disclosure. The Islamic Organization for Medical Sciences code was silent on both issues. Conclusion Codes regarding disclosure of terminal illness to patients and families differed markedly among Islamic countries. They were silent in one-third of the codes, and tended to favour a paternalistic/utilitarian, family-centred approach over an autonomous, patient-centred approach. (shrink)

The proliferation of ethics committees and ethics consultation services has engendered a discussion of the issue of the expertise of those who provide clinical ethics consultation services. In this paper, I discuss two aspects of this issue: the cognitive dimension or content knowledge that the clinical ethics consultant should possess and the practical dimension or set of dispositions, skills, and traits that are necessary for effective ethics consultation. I argue that the failure to differentiate and fully explicate these dimensions contributes (...) to the confusion over the issue of expertise and fuels, at least partly, the controversies about expertise (or authority) in ethics and the legitimacy of the use of ethical knowledge in clinical ethics consultation. (shrink)

It is often claimed that there is an obesity epidemic in affluent countries, and that obesity is one of the most serious public health threats in the developed world. I will argue that obesity is not an 'epidemic' in any useful sense of the word, and that classifying it as a public health problem requires us to make fairly controversial moral and empirical assumptions. While evidence suggests that the prevalence of obesity is on the rise, and that obesity can lead (...) to serious health problems ranging from diabetes to cardiovascular disease, this does not by itself show that obesity is a public health problem. (shrink)

Edited by four leading members of the new generation of medical and healthcare ethicists working in the UK, respected worldwide for their work in medical ethics, Principles of Health Care Ethics, Second Edition_is a standard resource for students, professionals, and academics wishing to understand current and future issues in healthcare ethics. With a distinguished international panel of contributors working at the leading edge of academia, this volume presents a comprehensive guide to the field, with state of the art introductions to (...) the wide range of topics in modern healthcare ethics, from consent to human rights, from utilitarianism to feminism, from the doctor-patient relationship to xenotransplantation. This volume is the Second Edition of the highly successful work edited by Professor Raanan Gillon, Emeritus Professor of Medical Ethics at Imperial College London and former editor of the Journal of Medical Ethics, the leading journal in this field. Developments from the First Edition include:_ The focus on ‘Four Principles Method’ is relaxed to cover more different methods in health care ethics. More material on new medical technologies is included, the coverage of issues on the doctor/patient relationship is expanded, and material on ethics and public health is brought together into a new section. (shrink)

Hospital ethics committees were created in the United States of America in the 1970s. Their aims were the education of the hospital personnel in the field of ethics, the development of policies and the publication of guidelines concerning ethical issues, as well as consultations and case reviews of hospitalized patients when an ethical concern was present. During the last thirty years, these committees disseminated, particularly in Western Europe. In this manuscript, we describe the benefit, but also some difficulties with these (...) committees, and we propose some solutions. The characteristics of these committees are discussed (i.e. typology of members, functioning and legitimacy). Finally, we carefully describe our local hospital clinical ethics committee in Geneva (Switzerland), which was founded in 1994 and it still very active. After fifteen years of experience, we remain strongly in favour of the implementation of such committees in any modern hospital. (shrink)

"A very good book indeed: there is scarcely an issue anyone has thought to raise about the topic which Childress fails to treat with sensitivity and good judgement....Future discussions of paternalism in health care will have to come to terms with the contentions of this book, which must be reckoned the best existing treatment of its subject."--Ethics. "A clear, scholarly and balanced analysis....This is a book I can recommend to physicians, ethicists, students of both fields, and to those most affected--the (...) patients themselves."--Edmund D. Pellegrino, John Carroll Professor of Medicine and Medical Humanities, Georgetown University Medical Center. (shrink)

The Internet has quickly gained popularity as a major source of health-related information, but its impact is unclear. Here, we investigate the extent to which advocacy websites for three neurodevelopmental disorders—cerebral palsy (CP), autism spectrum disorder (ASD) and fetal alcohol spectrum disorder (FASD)—inform stakeholders about treatment options, and discuss the ethical challenges inherent in providing such information online. We identified major advocacy websites for each disorder and assessed website accountability, the number, attributes, and accessibility of treatments described, and the valence (...) of treatment information. With the exception of FASD websites, we found that advocacy websites provide a plethora of information about a wide variety of readily available products and services. Treatment information is primarily targeted at families and is overwhelmingly encouraging, regardless of the type or conventionality of treatments. Many websites acknowledge corporate sponsors. While the majority do not overtly advertise or endorse specific brands, they also do not prominently display disclaimers about the nature and intent of treatment information. Thus, while advocacy websites are organized to serve as information clearinghouses, they implicitly appear to provide endorsement of selected treatments and services. We conclude with recommendations for new partnerships between government-funded health organizations, advocacy and investigators to make more transparent the role of online information in informing treatment options and improving the evaluation of information. (shrink)

In this essay, I utilize the concept of the echo, as formulated in the historical and methodological work of Michel Foucault and Joan W. Scott, to help theorize the historical relationship between health feminism and AIDS activism. I trace the echoes between health feminism and AIDS activism in order to present a more complex history of both movements, and to try to think through the ways that the coming together of these two struggles in a particular place and time—New York (...) City in the 1980s—created particular practices that might be effective in other times and places. The practice that I focus on here is one that I call 'doing queer love'. As I hope to show, 'doing queer love' both describes a particular history of health activism and opens up the possibility of bringing into being a different future than the one a conventional history of AIDS seems to predict. It is an historical echo that I believe we must try to hear now, not just in order to challenge a particular history of AIDS activism in the United States, but also in order to provide a model that can be useful for addressing the continuing problem of AIDS across the globe. (shrink)

The goal of an ethics case discussion is to find the best decision for the patient and the other persons involved (relatives, doctors, nurses and others) from an ethical point of view, in a communicative respect and from a psychosocial view. In the end, it may not mean changing one’s view or even one’s own position, but rather to exchange arguments, weight them and come to a consensus as to further action. The latter is important as the topics concern patients (...) and require action. For the moderator an ethics case discussion in this sense is no judgement, no taking over of responsibility for the decision result, no taking over of a leading role, and no team supervision. However, ethics case discussion has become a valuable tool to deal with moral conflicts in hospitals. Opportunities and problems of ethics case discussions are discussed. A 4-step approach for structuring the course of an ethics case discussion is presented. (shrink)

It is well known that prisoners’ human rights are often violated. In this chapter we examine whether guidelines can be effective in preventing such violations and in helping physicians resolve the significant conflicts of interest that they often face in trying to protect prisoners’ rights. We begin by explaining the role of clinical and ethical guidelines outside prisons, in the context of healthcare for non-incarcerated prisoners, and then the specific role of such guidelines within prisons, where the main concerns are (...) ensuring respect for the principle of equivalence of care, and for a prisoner patient’s autonomy in health care decisions. After reviewing and analysing various national and international guidelines, we review the literature and assess whether the good practices set out in these guidelines actually translate into changes in professional behaviour and consequent benefits for prisoners. It emerges that physicians both outside and within prisons tend to be insufficiently familiar with the relevant guidelines, and that they too infrequently use the guidance to make decisions, preferring instead to use personal codes of conduct. Guidelines designed specifically for the prison context are important to ensure equivalence of care and should be better known by health care personnel and other professional groups working in prison. Further guidelines should be developed that describe challenging situations and provide concrete guidance as to how to deal with them. (shrink)

If ethics consultation services influence medical decisions it is important to evaluate how ethical dilemmas are dealt with by clinical ethics committees (CECs). Such evaluation is rare. This study presents a feasible and practical method of evaluating case discussions in CECs and the results emerging from the use of this method. A written presentation of an end-of-life dilemma was sent to all Norwegian ethics committees. The committees were asked to deal with the case as they would do if it was (...) a real case, and to prepare a written report of the discussion. A majority of the committees approached the case systematically. All emphasized the importance of good communication with the next of kin. However, their conclusions varied, medical facts were interpreted differently, possible patient suffering was dealt with differently, and some committees revealed insufficient legal knowledge. Such findings are useful in the future education of committee members. (shrink)

Psychogenic non epileptic seizures (PNES) are clinical events of psychological nature. Video-electroencephalography monitoring (V-EEGM) is a valuable method for the diagnosis of PNES and may be combined with provocative tests to induce seizures. The use of placebo in provocative tests for the diagnosis of PNES is controversial because of associated deception, and contrasts with the use of truly decreasing epileptogenic threshold techniques such as hyperventilation and photo stimulation. We present a clinical case of a pregnant woman with a past history (...) of refractory epilepsy, admitted in the obstetric department due to unremitting seizures. In this clinical context, non-deceiving provocative tests such as hyperventilation and photo stimulation could be potentially harmful, nevertheless, the use of intravenous saline injection presented as a safer alternative to diagnose PNES and hence obviate an urgent caesarean. This case illustrates a disproportionate risk of causing harm when telling the truth, in comparison with the benefit of avoiding such risk, although deceiving the patient. This is a clinical example of how considerations concerning the use of placebo must be evaluated in an individual basis. (shrink)

Values-Based Medicine (VBM) is the theory and practice of clinical decision-making for situations in which legitimately different values are in play. VBM is thus to values what Evidence-Based Medicine (EBM) is to facts. The theoretical basis of VBM is a branch of analytic philosophy called philosophical value theory. As a set of practical tools, VBM has been developed to meet the challenges of value diversity as they arise particularly in psychiatry. These challenges are illustrated in this paper by a case (...) study of the differential diagnosis between delusion and religious experience. In a traditional model of scientific medicine, such challenges would be expected to become less pressing with advances in medical science. Philosophical value theory suggests, to the contrary, that scientific progress, through opening up an ever-wider range of choices, will increasingly bring the full range and diversity of human values into play not just in psychiatry but in all areas of medicine. The future, then, for medicine, is an integrated model in which VBM and EBM are equal partners in a genuinely human discipline. (shrink)

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase ‘‘quality of care’’ is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, hinges on its ability to improve (...) quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of ‘‘quality of care’’ are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, ‘‘quality of care,’’ in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that ‘‘quality of care’’ operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system. (shrink)

We live in an age of evidence-based healthcare, where the concept of evidence has been avidly and often uncritically embraced as a symbol of legitimacy, truth, and justice. By letting the evidence dictate healthcare decision making from the bedside to the policy level, the normative claims that inform decision making appear to be negotiated fairly—without subjectivity, prejudice, or bias. Thus, the term ‘‘evidence-based’’ is typically read in the health sciences as the empirically adequate standard of reasonable practice and a means (...) for increasing certainty. Supporters believe that evidence-based medicine (EBM) can introduce rational order to the deliberative processes of healthcare decision making. It is perhaps puzzling, then, to come across critical perspectives (typically arising from the humanities and the more theory-driven social sciences) raising concerns about a seeming technogovernance being introduced by this deferral to the evidence where power interests can be obfuscated by way of technical resolve. The critics holding this minority view argue that technological solutions to problems of knowledge and practice cannot replace medicine’s normative content. Against EBM’s democratic leanings toward transparency and accountability, medical criteria alone cannot decide valueladen ethically charged decisions. This paper attempts to explain and evaluate this important debate in the philosophy of medicine, focusing specifically on the dispute over 'evidence-based women's health'. (shrink)

Because “evidence” is at issue in evidence-based medicine (EBM), the critical responses to the movement have taken up themes from post-positivist philosophy of science to demonstrate the untenability of the objectivist account of evidence. While these post-positivist critiques seem largely correct, I propose that when they focus their analyses on what counts as evidence, the critics miss important and desirable pragmatic features of the evidence-based approach. This article redirects critical attention toward EBM’s rigid hierarchy of evidence as the culprit of (...) its objectionable epistemic practices. It reframes the EBM discourse in light of a distinction between objectivist and pragmatic epistemology, which allows for a more nuanced analysis of EBM than previously offered: one that is not either/or in its evaluation of the decision-making technology as either iconoclastic or creedal. -/- . (shrink)

When, if ever, can healthcare provider's lay claim to knowing what is best for their patients? In this paper, I offer a taxonomy of clinical disagreements. The taxonomy, I argue, reveals that healthcare providers often can lay claim to knowing what is best for their patients, but that oftentimes, they cannot do so *as* healthcare providers.

The truth about health care policy lies between two exaggerated views: a market view in which individuals purchase their own health care from profit maximizing health-care firms and a control view in which costs are controlled by regulations limiting which treatments health insurance will pay for. This essay suggests a way to avoid on the one hand the suffering, unfairness, and abandonment of solidarity entailed by the market view and, on the other hand, to diminish the inflexibility and inefficiency of (...) the control view. It suggests that the way to mitigate these problems is to recognize the malleability of motivation and the range of factors, in addition to financial incentives, that may influence the behavior of patients and especially physicians. (shrink)

As we die, our respiratory pattern is altered and we seem to gasp and struggle for each breath. Such gasping is commonly seen as a clear sign of dyspnoea and suffering by families and loved ones, however, it is unclear whether it is perceived at all by the dying person. Narcotics and sedatives do not seem to affect these gasping respirations. In this issue of the Journal of Medical Ethics, we are asked to consider whether the last gasp of a (...) dying patient could be or, perhaps, even should be avoided by administering neuromuscular blockers to palliate dying patients. For many reasons, such as our current failure to alleviate pain and distress, stories of inadequate analgesia and sedation in critically ill paralysed patients and the inability to know the intent—whether to palliate or to euthanise—it would seem that administering neuromuscular blockers should not be ethically permissible. (shrink)

It is usually appropriate for adults to make significant decisions, such as about what kinds of medical treatment to undergo, for themselves. But sometimes impairments are suffered - either temporary or permanent - which render an individual unable to make such decisions. The Mental Capacity Act 2005 sets out the conditions under which it is appropriate to regard an individual as lacking the capacity to make a particular decision (and when provisions should be made for a decision on their behalf). (...) -/- To what extent does having capacity require the endorsement of certain values? Drawing on Owens et al (2009), I assess the extent to which understanding relevant information and weighing it in coming to a decision requires certain evaluative commitments. With reference to literature on anorexia nervosa and decisions informed by religious beliefs, I argue that it is difficult to avoid the conclusion that the conditions for capacity are value-laden, and that if this is so it is important to open discussion about which patterns of distorted valuing undermine capacity, and why. (shrink)

This paper is based on the findings from a study in which social workers in healthcare settings were asked for their perspectives on cultural and racial difference as these apply to their practice with racialized clients. In examining the varied practice philosophies and approaches they employ, we find that older practice models based on problematized knowledge about racialized Others are being, alternately, reinstated and contested. In grappling with how to practise, participants describe approaches that, in many cases, effectively individualize clients (...) and ignore hierarchies and systems of domination. Following Sarah Ahmed's work on ethical encounters (Strange Encounters, Routledge, London, 2000), we argue for a socially and historically informed consideration of power relations as they shape professional practice. (shrink)

The aim of this thesis is to examine the concept of virtue ethics in Stanley Hauerwas's understanding of virtue and delineate how that contributes to his ethical reasoning and his comprehension of medical ethics. The first chapter focuses on the shift that occurred in moral theory under the stance of the Enlightenment that eroded the traditional idea of morality as the formation of the self, allowing space for new concepts that dismissed the importance of the agent in the ethical task (...) of seeking the good. In the second chapter, the three main ideas (character, vision, and narrative) that make up Hauerwas' ethical theory are examined with a particular attention to the importance of agency in moral life. The third chapter describes how Hauerwas' medical ethics, informed by his moral theory based on character, vision, and narrative, is relevant to medical ethics. Hauerwas argues that because medicine is a form of human activity with internal goods and standards of excellence intrinsic to its practice, it requires taking into account the notion of agency in the healing relationship. Finally, in the last chapter the specific religious discourse of Hauerwas' ethics is discussed in relation to secular medical ethics. In other words, this thesis raises the question of whether the reduction of medical ethics to a set of principles, as it is mostly the case today, represents a suitable picture of the reality of moral life in medicine. (shrink)

“Aging and Disasters,” is an effort to tell a consistent and compelling story about the elderly amidst catastrophic disaster, and to then develop an ethical analysis and practical strategy for addressing the unique situation of the elderly. In the first portion of the chapter I make the case that the elderly are routinely overlooked amidst catastrophic disasters, and thereby often suffer disproportionately relative to the general population. More than being just a vulnerable population of people, the elderly are susceptible to (...) additional and compound harms. A failure to recognize the special needs of the elderly population will consistently lead to their marginalization in disaster response efforts. Therefore, in the second section of the chapter, I emphasize our ethical obligations to (1) responsible planning prior to a disaster taking place and also to (2) promoting and maintaining effective communication and collaboration both in planning for and responding to a major disaster as two elements of an approach that seeks to address the particularity of the elderly relative to major disasters. To further specify and make meaningful these broad commitments, I introduce an ethics of place holding, arising out of work by Hilde Lindemann and Iris Marion Young, as an important framework for analysis and assessment. In the final portion of the chapter, I offer some concrete recommendations for a renewed approach to disaster planning and response that is conscious of the elderly amidst catastrophic disasters. (shrink)

In the UK an increasing number of Clinical Ethics Committees (CECs) have been developed mainly in response to local need and interest. Their functions include education of health professionals, of policy and guideline development, and case review (both retrospective analysis of topics and advice on acute cases). The UK Clinical Ethics Network, a charitable foundation provides CEC s with help, support and advice and enables them to share their experience The legal status of UK CECs is unclear but some legal (...) commentators have suggested that CECs lack competencies and procedural rules necessary for acute case review. The UKCEN has proposed core competencies for CECs that lists the ethical, operational and procedural skills, knowledge and personal attributes required and how they may be acquired, assessed and maintained. Their implementation might lead to the development of ethical and legal governance which should benefit to future patient care. (shrink)

This paper critically assesses the model of evaluation of scientific research for democratic societies defended by Philip Kitcher. The “significant truth” approach proposes a viable alternative to two classic images of science: that of the “critics”, who believe that science always serves the interests of the powerful and that of the “faithful”, who argue that the pursuit of scientific knowledge is always valuable and necessary. However, the democratic justification of Kitcher’s proposal is not compatible with the ethical problems generated by (...) the international biomedical research in developing countries. To overcome this problem, I revise the national democratic framing of the significant truth approach in light of the theory of justice of John Rawls. (shrink)

Failings in patient care and quality in NHS Trusts have become a recurring theme over the past few years. In this paper, we examine the Care Quality Commission’s Guidance about Compliance : Essential Standards of Quality and Safety and ask how NHS Trusts might be better supported in fulfilling the regulations specified therein. We argue that clinical ethics committees (CECs) have a role to play in this regard. We make this argument by attending to the many ethical elements that are (...) highlighted in the Commission’s Regulations and by providing practical examples of how CECs can (and in some case already do) provide ethics support to health professionals and trusts. Although CECs have been traditionally associated with case consultation, i.e., discrete problems caused by individual circumstances, in the previous 10 years the literature suggests that clinical ethics services have become more integrated into the life of the health care organization and are increasing construed as proactive agents of systematic change. We provide evidence from a recent survey of UK clinical ethics services that this trend is present in the UK. (shrink)